CRANFIELD UNIVERSITY
OLUSEUN ADEOGUN
INFORMATICS FOR DEVICES WITHIN TELEHEALTH SYSTEMS
FOR MONITORING CHRONIC DISEASES
SCHOOL OF APPLIED SCIENCES
PhD
Academic Year: 2010 - 2011
Supervisors:
Dr J.R. Alcock and Dr A. Tiwari
April 2011
CRANFIELD UNIVERSITY
SCHOOL OF APPLIED SCIENCES
PhD
Academic Year 2010 - 2011
OLUSEUN ADEOGUN
INFORMATICS FOR DEVICES WITHIN TELEHEALTH SYSTEMS
FOR MONITORING CHRONIC DISEASES
Supervisors:
Dr J.R. Alcock and Dr A. Tiwari
April 2011
This thesis is submitted in partial fulfilment of the requirements for
the degree of PhD
© Cranfield University 2011. All rights reserved. No part of this
publication may be reproduced without the written permission of the
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ABSTRACT
Preliminary investigation at the beginning of this research showed that informatics on point-of-care (POC) devices was limited to basic data generation and processing.
This thesis is based on publications of several studies during the course of the research.
The aim of the research is to model and analyse information generation and exchange in telehealth systems and to identify and analyse the capabilities of these systems in managing chronic diseases which utilise point-of-care devices. The objectives to meet the aim are as follows: (i) to review the state-of-the-art in informatics and decision support on point-of-care devices. (ii) to assess the current level of servitization of POC devices used within the home environment. (iii) to identify current models of information generation and exchange for POC devices using a telehealth perspective. (iv) to identify the capabilities of telehealth systems. (v) to evaluate key components of telehealth systems (i.e. POC devices and intermediate devices). (vi) to analyse the capabilities of telehealth systems as enablers to a healthcare policy.
The literature review showed that data transfer from devices is an important part of generating information. The implication of this is that future designs of devices should have efficient ways of transferring data to minimise the errors that may be introduced through manual data entry/transfer.
The full impact of a servitized model for point-of-care devices is possible within a telehealth system, since capabilities of interpreting data for the patient will be offered as a service (c.f. NHS Direct).
This research helped to deduce components of telehealth systems which are important in supporting informatics and decision making for actors of the system. These included actors and devices. Telehealth systems also help
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facilitate the exchange of data to help decision making to be faster for all actors concerned.
This research has shown that a large number of capability categories existed for the patients and health professionals. There were no capabilities related to the caregiver that had a direct impact on the patient and health professional. This was not surprising since the numbers of caregivers in current telehealth systems was low.
Two types of intermediate devices were identified in telehealth systems: generic and proprietary. Patients and caregivers used both types, while health professionals only used generic devices. However, there was a higher incidence of proprietary devices used by patients. Proprietary devices possess features to support patients better thus promoting their independence in managing their chronic condition.
This research developed a six-step methodology for working from government objectives to appropriate telehealth capability categories. This helped to determine objectives for which a telehealth system is suitable.
Keywords:
Point-of-care, informatics, data processing, long term conditions care, chronic care, point-of-care testing, medical device, PSS, product-service system, glucometers, information exchange, model, telehealth, capability, capabilities, functionality, system, chronic diseases, actor-centric, categories, diabetes, advice, intermediate device, types, location, user, healthcare, policy
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ACKNOWLEDGEMENTS
I express my appreciation to my supervisors Dr Jeffrey Alcock and Dr Ashutosh Tiwari for their support and advice throughout the course of my research.
I am grateful to my subject adviser Prof Jeremy Ramsden and my review chairman Prof Jane Rickson for their constructive feedback during my reviews. Many thanks also go to the EPSRC and Cranfield Innovative Manufacturing Research Centre for funding my research.
Thanks to the people who completed questionnaires to help validate my research. Your feedback has been very helpful.
I would like to thank my family: My parents: Thanks for starting me on this journey and being there; my brother: for his encouragement; the Adeoguns, the Toluses and Taiwos: for their encouragement and moral support throughout this journey.
I am sincerely grateful to my husband for his encouraging words and understanding through the research.
Finally, words are not enough to express my gratitude; I give all glory to God who has made it all possible.
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TABLE OF CONTENTS
ABSTRACT ... i
ACKNOWLEDGEMENTS... iii
PUBLICATIONS ... xii
LIST OF FIGURES ... xiii
LIST OF TABLES ... xvi
LIST OF ABBREVIATIONS ... xx
1 Introduction ... 21
1.1 Background ... 21
1.2 Motivation ... 21
1.3 Overall Context ... 22
1.4 Link to thesis chapters ... 22
1.5 Terminology ... 23
1.5.1 Point-of-care devices ... 23
1.5.2 Telehealth and telemedicine ... 24
1.5.3 Long term conditions ... 25
1.5.4 Medical and health informatics... 26
1.5.5 Decision making/decision support ... 28
1.6 Research goals ... 29 1.6.1 Research context ... 29 1.6.2 Research aim ... 30 1.6.3 Research objectives ... 30 1.6.4 Research approach ... 31 1.7 Thesis Structure ... 36 1.7.1 Introductory chapters ... 36 1.7.2 Studies ... 37 1.7.3 Summary ... 40
2 A Review of Informatics for Decision Support in Point-of-Care Devices for Long Term Conditions Care ... 41
Abstract ... 41
2.1 Introduction ... 41
2.1.1 Scope of the review ... 41
2.1.2 Aim of review ... 42
2.1.3 Research Questions ... 42
2.1.4 What this review does not cover ... 43
2.1.5 Background ... 44
2.2 Methodology ... 47
2.2.1 Keyword search ... 47
2.2.2 Organisation of literature ... 48
2.3 An informatics model applied to point-of-care devices ... 49
2.3.1 Data ... 49
2.3.2 Information ... 55
2.3.3 Decision support systems in health ... 57
2.4 Discussion ... 60
2.4.1 Improvements for data ... 61
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2.4.3 Information synthesis ... 62
2.4.4 Knowledge and decision support ... 63
2.5 Conclusions ... 68
3 Informatics-Based Product-Service Systems for Point-of-Care Devices ... 69
Abstract ... 69
3.1 Introduction ... 69
3.1.1 Point-of-care biomedical devices ... 69
3.1.2 Medical/Health informatics ... 71
3.1.3 Product-service systems ... 71
3.2 Aim ... 72
3.3 The current model of usage of home environment point-of-care devices ... 73
3.4 Drivers for change ... 75
3.4.1 Drivers from literature ... 75
3.4.2 Plans by UK Government regarding changes in healthcare ... 76
3.4.3 User choices and expectations ... 84
3.5 Use- and Result-oriented PSS for Point-of-care testing devices ... 87
3.5.1 Examples of services ... 87
3.5.2 Advantages of POCT Devices in a PSS ... 89
3.5.3 Informatics resources required for POCT devices to support a move towards more servitization ... 89
3.5.4 Challenges of POCT Devices in a PSS ... 91
3.5.5 A proposed example of an informatics system required for a result-oriented PSS based on POCT devices ... 91
3.6 Limitations and future work ... 93
3.7 Conclusions ... 93
4 Models of Information Exchange for UK telehealth systems ... 95
Abstract ... 95
4.1 Introduction ... 96
4.1.1 Definitions of telehealth ... 96
4.1.2 Benefits of telehealth for point-of-care devices ... 96
4.1.3 Drivers for telehealth ... 98
4.1.4 Motivation ... 98
4.1.5 Research questions ... 99
4.2 Methodology ... 99
4.2.1 Modelling the telehealth offerings ... 100
4.2.2 Validation of the telehealth offerings ... 101
4.3 Results ... 102
4.3.1 Entities ... 102
4.3.2 Organisations evaluated ... 103
4.3.3 Baseline model ... 103
4.3.4 Validating results ... 104
4.3.5 Constraints by organisations when implementing telehealth offerings. ... 104
4.3.6 Standards ... 105
4.4 Discussion ... 105
4.4.1 Comparing the telehealth offerings ... 105
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4.5 Strengths and weaknesses of the study ... 117
4.6 Conclusion ... 118
5 Capabilities of telehealth systems ... 121
Abstract ... 121 5.1 Introduction ... 122 5.1.1 Aim of paper... 122 5.1.2 Definition of capability ... 122 5.2 Methodology ... 125 5.2.1 Compile capabilities ... 125 5.2.2 Identify categories ... 126
5.2.3 Representations of actor centric capabilities ... 127
5.3 Results ... 128
5.3.1 Patient ... 128
5.3.2 Caregiver ... 130
5.3.3 Health professional ... 130
5.3.4 Non-actor entities ... 132
5.3.5 Overview of categorised capabilities for actors within the individual telehealth offerings ... 134
5.4 Discussion ... 139
5.4.1 Overview of capability categories ... 140
5.4.2 Capabilities for patients ... 140
5.4.3 Capabilities for caregivers ... 142
5.4.4 Capabilities for health professionals ... 143
5.4.5 Capabilities by non-actor entities ... 146
5.5 Limitations and further work ... 148
5.6 Conclusions ... 149
6 Evaluation of the state-of-the-art in informatics in glucometers ... 151
Abstract ... 151 6.1 Introduction ... 151 6.1.1 Background on diabetes ... 152 6.1.2 Monitoring diabetes ... 152 6.1.3 Glucometers... 153 6.1.4 Aim ... 154 6.2 Methodology ... 154 6.3 Results ... 155
6.3.1 Information before testing ... 155
6.3.2 Testing ... 155
6.3.3 On-device data manipulation after testing ... 156
6.3.4 Off-device data management software ... 159
6.3.5 On-device and off-device ‗advice‘ ... 160
6.4 Discussion ... 162
6.4.1 Information provided to users... 162
6.4.2 User interaction with the results ... 163
6.4.3 Glucometers and informatics ... 164
6.5 Conclusion ... 165
7 Intermediate devices in telehealth systems: types available, where they are found and who uses them? ... 167
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7.1 Introduction ... 168
7.1.1 Research Context – What is an Intermediate Device in a Telehealth System? ... 168
7.1.2 Research questions ... 170
7.2 Methodology ... 171
7.2.1 What are the types of intermediate devices that can be used in telehealth systems? ... 171
7.2.2 Where are intermediate devices located within telehealth systems? ... 171
7.2.3 Which entities do intermediate devices receive their inputs and provide their outputs to? ... 173
7.2.4 Which types of intermediate devices are used by the actors of the system? 174 7.3 Results ... 174
7.3.1 What are the types of intermediate devices that can be used in telehealth systems? ... 174
7.3.2 Where are intermediate devices located within telehealth systems? ... 175
7.3.3 Which entities do intermediate devices receive their inputs and provide their outputs to? ... 177
7.3.4 Which types of intermediate devices are used by the actors of the system? 179 7.4 Discussion ... 180
7.4.1 Types of intermediate devices ... 180
7.4.2 ‗Informatic‘ location of devices ... 180
7.4.3 Inputs and outputs for intermediate devices ... 183
7.4.4 Are proprietary intermediate devices needed? ... 184
7.5 Limitations ... 185
7.6 Conclusions ... 185
8 Capabilities of Proprietary Intermediate Telehealth Devices ... 187
Abstract ... 187
8.1 Introduction ... 188
8.1.1 Previous case studies ... 189
8.1.2 The perspective of healthcare providers ... 189
8.1.3 Research questions ... 190
8.2 Method ... 190
8.2.1 Criteria for selecting devices ... 190
8.2.2 Data capture ... 191 8.2.3 Evaluation questions ... 193 8.2.4 Clustering ... 195 8.3 Results ... 196 8.3.1 Availability ... 196 8.3.2 Setup ... 197 8.3.3 Environments ... 197
8.3.4 Multiple conditions and point-of-care connection options ... 198
8.3.5 Multiple Users ... 200
8.3.6 Prompts, Reminders and Confirmations ... 200
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8.3.8 Advice and Communication with the Health professional ... 202
8.3.9 Historical data ... 203
8.3.10 Authentication ... 203
8.3.11 Automatic or manual results input ... 203
8.3.12 Device Inputs ... 204
8.3.13 Information transfer technology ... 205
8.3.14 Data transfer destination ... 207
8.4 Discussion ... 208
8.4.1 Key capabilities of current proprietary intermediate devices ... 208
8.4.2 Provider perspective ... 209
8.4.3 Patient perspective ... 210
8.4.4 Health professional perspective ... 211
8.4.5 Payer perspective ... 212
8.5 Limitations ... 212
8.6 Conclusions ... 212
9 Applying capabilities of telehealth systems to a healthcare policy ... 215
Abstract ... 215
9.1 Introduction ... 216
9.1.1 Motivation ... 216
9.1.2 Research Questions ... 216
9.1.3 What are telehealth systems? ... 217
9.1.4 Focus of this paper ... 218
9.2 Methodology ... 218
9.2.1 What are the key government objectives proposed for the future of healthcare administration? ... 218
9.2.2 Are telehealth system solutions possible for delivering particular government healthcare objectives? ... 220
9.2.3 What are the possible actions needed to meet the government objectives? ... 220
9.2.4 What are the equivalent capability categories from current telehealth systems that can be used to deliver the government objectives? 221 9.2.5 Additional Capabilities ... 221
9.2.6 Worked example ... 222
9.2.7 Validation of results ... 226
9.3 Results ... 226
9.3.1 Is a telehealth system possible for Objective 1 – ―rights for patients‖? ... 227
9.3.2 Is a telehealth system possible for Objective 2 – ―responsibilities of patients‖? ... 228
9.3.3 Is a telehealth system possible for Objective 3 – ―a preventative, people-centred, productive NHS‖? ... 228
9.3.4 Is a telehealth system possible for Objective 4 – ―supporting people to get and stay healthy‖? ... 229
9.3.5 Is a telehealth system possible for Objective 5 – ―delivering through partnerships‖? ... 230 9.3.6 Is a telehealth system possible for Objective 6 – ―reaching out to people‖? 231
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9.3.7 Is a telehealth system possible for Objective 7 – ―diagnosing early‖? 231
9.3.8 Is a telehealth system possible for Objective 8 – ―providing high
quality services – treating patients well‖? ... 232
9.3.9 Is a telehealth system possible for Objective 9 – ―safer care‖? . 233 9.3.10 Is a telehealth system possible for Objective 10 – ―improving patient satisfaction – increasing choice and control‖? ... 234
9.3.11 Is a telehealth system possible for Objective 11 – ―effective care – transforming the lives of patients with long-term conditions‖? ... 235
9.3.12 Is a telehealth system possible for Objective 12 – ―social care‖? 235 9.4 Discussion ... 236
9.4.1 Objectives where a telehealth system was not possible ... 236
9.4.2 Key statements where a telehealth system was not possible ... 237
9.4.3 Objectives where a telehealth system was possible ... 238
9.4.4 Capability categories applied to key statements ... 239
9.4.5 Additional capability categories required for future telehealth systems 241 9.5 Validation outcome... 244
9.5.1 Government objectives evaluated as entirely not deliverable by a telehealth system (Objectives 1, 2, 9 and 12) ... 244
9.5.2 Government objectives evaluated as partially deliverable by a telehealth system (Objectives 3, 4, 5, 7, 8 and 10) ... 247
9.5.3 Government objectives evaluated as completely deliverable by a telehealth system (Objectives 6 and 11) ... 252
9.6 Limitations ... 253
9.7 Conclusions ... 254
10 Discussion of Results ... 255
10.1 Chapter 2 – a review of informatics for decision support in point-of-care devices for long term conditions care ... 255
10.1.1 Major findings... 255
10.1.2 Contribution... 255
10.2 Chapter 3 – informatics-based product-service systems for point-of-care devices ... 256
10.2.1 Major findings... 256
10.2.2 Contribution... 257
10.3 Chapter 4 – models of information exchange for UK telehealth systems 257 10.3.1 Major findings... 257
10.3.2 Contribution... 258
10.4 Chapter 5 – capabilities of telehealth systems ... 258
10.4.1 Major findings... 258
10.4.2 Contribution... 259
10.5 Chapter 6 – evaluation of the state-of-the-art in informatics in glucometers. ... 260
10.5.1 Major findings... 260
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10.6 Chapter 7 – intermediate devices in telehealth systems: types
available, where they are found and who uses them? ... 263
10.6.1 Major findings... 263
10.6.2 Contribution... 263
10.7 Chapter 8 – capabilities of proprietary intermediate devices ... 264
10.7.1 Major findings... 264
10.7.2 Contribution... 264
10.8 Chapter 9 – applying capabilities of telehealth systems to a healthcare policy 265 10.8.1 Major findings... 265 10.8.2 Contribution... 265 10.9 Limitations of studies ... 265 10.10 Future work ... 267 10.11 Conclusions ... 267 REFERENCES ... 271 APPENDICES ... 297
Appendix A (For Chapter 4) – Supplementary material showing the details of each telehealth offering ... 297
Appendix B (For Chapter 5) – Capabilities of telehealth systems ... 315
Appendix C (For Chapter 7) – Supplementary material of the flow path diagrams showing the arrangement of entities and the type of intermediate devices connecting them. ... 325
Appendix D (For Chapter 9) – Applying capabilities of telehealth systems to a healthcare policy ... 331
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PUBLICATIONS
Edited versions of the chapters have been published, submitted or will be submitted as follows:
Chapter 2 Adeogun, O., Tiwari, A. and Alcock, J.R., ―A Review of Informatics for Decision Support in Point-of-Care devices for Long Term Conditions Care‖.
International journal of medical informatics (to be submitted)
Chapter 3 Adeogun, O., Tiwari, A. and Alcock, J. R. (2010), "Informatics-based product-service systems for point-of-care devices", CIRP Journal of
Manufacturing Science and Technology, vol. 3, no. 2, pp. 107-115.
Chapter 4 Adeogun, O., Tiwari, A., Alcock, J. R. (2011), ―Models of Information exchange for UK telehealth systems‖, International journal of medical
informatics, vol. 80, no. 5, pp. 359-370.
Chapter 5 Adeogun, O., Tiwari, A., Alcock, J. R., ―Capabilities of telehealth systems‖,
Journal of the American Medical Informatics Association (to be submitted)
Chapter 6 Ajai, O., Tiwari, A. and Alcock, J. R. (2009), ―Evaluation of the state-of-the-art in informatics in glucometers‖, Informatics for Health and Social Care, vol. 34, no. 3, pp. 171-179.
Chapter 7 Adeogun, O., Tiwari, A., Alcock, J. R., ―Intermediate devices in telehealth systems: types available, where they are found and who uses them‖?
International journal of medical informatics (submitted)
Chapter 8 Adeogun, O., Tiwari, A., Alcock, J. R. (2011), ―Capabilities of Proprietary Intermediate Telehealth Devices‖, Telemedicine and e-Health. (accepted)
Chapter 9 Adeogun, O., Tiwari, A., Alcock, J. R., ―Applying capabilities of telehealth systems to a healthcare policy‖, International Journal of Technology
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LIST OF FIGURES
Figure 1-1 – Risk factor links between chronic conditions. (1: Nichols and Moler (2010); 2: Adler et al. 2000; 3: Whaley-Connell et al. 2008; 4: Kissela et al.
2005) ... 26
Figure 1-2 – Approach followed in this research (the details of methods used are shown in grey) ... 36
Figure 2-1 – The domains investigated in this review and their linkages ... 44
Figure 2-2 – A simple health informatics model (Desrosieres, 1998) ... 49
Figure 2-3 – Example of a decision-making process by the health professional ... 65
Figure 2-4 – A proposal of on-device decision support for patients ... 66
Figure 3-1 – User comments showing factors influencing their choice of glucometer ... 86
Figure 3-2 – User comments showing features that users would prefer to be incorporated in future glucometers ... 87
Figure 3-3 – A proposed view of PSS for home care devices ... 93
Figure 4-1 – The baseline model for information exchange: all systems have these functions ... 104
Figure 4-2 – The dominant model showing the entities that appear in more than 6 of the offerings ... 113
Figure 4-3 – A model comprising functionalities observed in all the offerings for information exchange ... 116
Figure 5-1 – The patient centred view of a telehealth system ... 129
Figure 5-2 – The caregiver centred view of the telehealth system. ... 130
Figure 5-3 – The health professional centred view of the telehealth system .. 131
Figure 5-4 – Non-actor capabilities of a telehealth system: A=Database; B=EPR ... 132
Figure 5-5 – Non-actor capabilities of a telehealth system: C=Intermediate device (with display); D=Intermediate device (without display); E=web portal ... 133
Figure 5-6 – Patient capabilities from current telehealth offerings ... 136
Figure 5-7 – Caregiver capabilities from current telehealth offerings ... 137
Figure 5-8 – Health professional capabilities from current telehealth offerings ... 139
Figure 6-1 – Duration of the test ... 157
Figure 6-2 – Types of averages calculated on glucometers ... 159
Figure 7-1 – The baseline telehealth model (Adeogun et al. 2011a) ... 168
Figure 7-2 – The fully-featured telehealth model highlighting locations of intermediate devices (Adeogun et al. 2011a) ... 169
Figure 9-1 – Generic steps 1-3 showing how to develop a government healthcare objective into detailed explanations of plans for implementation ... 219
Figure 9-2 – Worked example showing methodological steps 1 to 3 in developing the government objective ―a preventative, people-centred, productive NHS‖ into detailed explanations... 223
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Figure A-1 – Offering A representing a telehealth system for diabetes management ... 298 Figure A-2 – Offering B representing a telehealth system for monitoring several chronic conditions ... 300 Figure A-3 – Offering C representing a telehealth system for monitoring several chronic conditions ... 301 Figure A-4 – Offering D representing a telehealth system for monitoring cardiac and respiratory conditions ... 303 Figure A-5 – Offering E representing a telehealth system for managing and preventing long term conditions ... 305 Figure A-6 – Offering F representing a telehealth system for monitoring several chronic conditions ... 306 Figure A-7 – Offering G representing a telehealth system for monitoring several chronic conditions ... 307 Figure A-8 – Offering H representing a telehealth system for monitoring several chronic conditions ... 308 Figure A-9 – Offering I representing a telehealth system for monitoring several chronic conditions ... 310 Figure A-10 – Offering J representing a telehealth system for monitoring several chronic conditions ... 311 Figure A-11 – Offering K representing a telehealth system for monitoring several chronic conditions ... 312 Figure A-12 – Offering L representing a telehealth system for monitoring several chronic conditions ... 314 Figure C-1 – Intermediate devices located between patients and other entities
... 326 Figure C-2 – Intermediate devices located between caregivers and web portals (The dotted arrow indicates that this direction was assumed.) ... 327 Figure C-3 – Intermediate devices located between the health professional and multiple entities. ... 328 Figure C-4 – Intermediate devices located between point-of-care devices and other entities ... 329 Figure C-5 – Intermediate devices located between web portals and health professionals ... 330 Figure D.1-1 – Methodological steps 1 to 3 in developing the government objective ―rights for patients‖ into detailed explanations ... 331 Figure D.2-1 – Methodological steps 1 to 3 in developing the government objective ―responsibilities of patients‖ into detailed explanations ... 333 Figure D.3-1 – Methodological steps 1 to 3 in developing the government objective ―a preventative, people-centred, productive NHS‖ ... 334 Figure D.4-1 – Methodological steps 1 to 3 in developing the government objective ―supporting people to get and stay healthy‖ ... 336 Figure D.5-1 – Methodological steps 1 to 3 in developing the government objective ―delivering through partnerships‖ into detailed explanations .... 339 Figure D.6-1 – Methodological steps 1 to 3 in developing the government objective ―reaching out to people‖ into detailed explanations ... 342 Figure D.7-1 – Methodological steps 1 to 3 in developing the government objective ―diagnosing early‖ into detailed explanations ... 347
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Figure D.8-1 – Methodological steps 1 to 3 in developing the government objective ―providing high quality services – treating patients well‖ into detailed explanations (part 1) ... 350 Figure D.8-2 – Methodological steps 1 to 3 in developing the government objective ―providing high quality services – treating patients well‖ into detailed explanations (part 2) ... 351 Figure D.9-1 – Methodological steps 1 to 3 in developing the government objective ―safer care‖ into detailed explanations ... 354 Figure D.10-1 – Methodological steps 1 to 3 in developing the government objective ―improving patient satisfaction – increasing choice and control‖ into detailed explanations (part 1) ... 355 Figure D.10-2 – Methodological steps 1 to 3 in developing the government objective ―improving patient satisfaction – increasing choice and control‖ into detailed explanations (part 2) ... 356 Figure D.11-1 – Methodological steps 1 to 3 in developing the government objective ―effective care – transforming the lives of patients with long-term conditions‖ into detailed explanations (part 1) ... 359 Figure D.11-2 – Methodological steps 1 to 3 in developing the government objective ―effective care – transforming the lives of patients with long-term conditions‖ into detailed explanations (part 2) ... 360 Figure D.11-3 – Methodological steps 1 to 3 in developing the government objective ―effective care – transforming the lives of patients with long-term conditions‖ into detailed explanations (part 3) ... 361 Figure D.12-1 – Methodological steps 1 to 3 in developing the government objective ―social care‖ into detailed explanations ... 367 Figure D.14-1 – Methodological steps 1 to 3 in developing the government objective ―rights for patients‖ into detailed explanations ... 370
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LIST OF TABLES
Table 1-1 – Sub domains of informatics (MeSH, 2011b) ... 28
Table 1-2 – Examples of DSSs used in healthcare ... 29
Table 2-1 – Examples of point-of-care testing devices ... 46
Table 3-1 – Action point 1 from Saving Lives: Our Healthier Nation ... 77
Table 3-2 – Action point 2 from Saving Lives: Our Healthier Nation ... 78
Table 3-3 – Action point 3 from Saving Lives: Our Healthier Nation ... 79
Table 3-4 – Principle 1 from Choosing Health: Making healthy choices easier 80 Table 3-5 – Principle 2 from Choosing Health: Making healthy choices easier 81 Table 3-6 – Principle 3 from Choosing Health: Making healthy choices easier 81 Table 3-7 – Theme 1 from Our health, our care, our say: a new direction for community services ... 82
Table 3-8 – Theme 2 from Our health, our care, our say: a new direction for community services ... 83
Table 3-9 – Theme 3 from Our health, our care, our say: a new direction for community services ... 84
Table 4-1 – Key to symbols used to draw telehealth offerings ... 101
Table 4-2 – Comparison of the information path diagrams – chronic diseases being monitored ... 106
Table 4-3 – Comparison of the information path diagrams – preparing for data transfer stage ... 107
Table 4-4 – Comparison of the information path diagrams – data transfer from patient to health professional ... 108
Table 4-5 – Comparison of the information path diagrams – information generation and information transfer to patient ... 111
Table 4-6 – Comparison of the information path diagrams – data storage and accessibility ... 112
Table 5-1 – Telehealth studies showing the management of chronic diseases ... 124
Table 5-2 – Distribution of capability categories for actors ... 140
Table 6-1– A summary of comments provided on five glucometers to annotate the results ... 159
Table 7-1 – Types of intermediate devices found in telehealth systems. ... 175
Table 7-2 – Overview of ‗informatic location‘s for different types of intermediate devices. ... 176
Table 7-3 – Entities that intermediate devices received their inputs from ... 178
Table 7-4 – Entities that intermediate devices provided outputs to ... 179
Table 7-5 – Types of intermediate devices used by actors of telehealth systems ... 180
Table 7-6 – Summary of classes of intermediate devices based on ‗informatic location‘ (ID is ‗intermediate device‘) ... 181
Table 8-1 – Proprietary intermediate devices with data display capabilities ... 192
Table 8-2 – Criteria used to assess proprietary intermediate devices (Setup/configuration) ... 193
Table 8-3 – Criteria used to assess proprietary intermediate devices (Available features) ... 194
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Table 8-4 – Criteria used to assess proprietary intermediate devices (Inputs) 195 Table 8-5 – Criteria used to assess proprietary intermediate devices (Outputs)
... 195 Table 8-6 – Availability of proprietary intermediate devices (Key: V=Variable, depending on request) ... 197 Table 8-7 – Environments in which proprietary intermediate devices can be used ... 198 Table 8-8 – Chronic conditions managed by proprietary intermediate devices. (Where the chronic condition is shown as unspecified, this means that the organisation did not describe the condition) ... 199 Table 8-9 – Types of point-of-care devices providing inputs for proprietary intermediate devices ... 200 Table 8-10 – Proprietary intermediate devices designed for multiple users ... 200 Table 8-11 – Prompts available on proprietary intermediate devices ... 201 Table 8-12 – Alerts to patients on proprietary intermediate devices ... 202 Table 8-13 – Advice provided to users on proprietary intermediate devices .. 203 Table 8-14 – Automatic or manual results input for proprietary intermediate devices ... 204 Table 8-15 – Proprietary intermediate device inputs ... 204 Table 8-16 – Wired information transfer technology between point-of-care devices and proprietary intermediate devices ... 205 Table 8-17 – Wireless information transfer technology between point-of-care devices and proprietary intermediate devices ... 207 Table 8-18 – Information transfer technology between proprietary intermediate devices and other components of telehealth systems ... 207 Table 8-19 – Data transfer destination for intermediate devices ... 208 Table 9-1 – Worked example showing methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 3 ... 224 Table 9-2 – Worked example showing methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 3-1 ... 225 Table 9-3 – Worked example showing methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 3-3 ... 225 Table 9-4 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 1... 227 Table 9-5 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 2... 228 Table 9-6 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 4... 229 Table 9-7 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 5... 230 Table 9-8 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 6... 231 Table 9-9 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 7... 231
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Table 9-10 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 8 ... 232 Table 9-11 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 9 ... 233 Table 9-12 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 10 ... 234 Table 9-13 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 11 ... 235 Table 9-14 – Methodological step 4 of whether a telehealth system is possible for the details of key statements for objective 12 ... 235 Table 9-15 – Objectives and key statements where a telehealth system was not a possibility ... 237 Table 9-16 – Distribution of capabilities of telehealth systems applied to key statements within government objectives ... 240 Table 9-17 – Summary of capability categories applied to government objectives ... 241 Table 9-18 – List of additional capability categories required in proposed telehealth systems ... 243 Table 9-19 – Questionnaire responses for objectives 1, 2, 9 and 12 ... 245 Table 9-20 – Questionnaire responses for objective 3 ... 247 Table 9-21 – Questionnaire responses for objective 4 ... 248 Table 9-22 – Questionnaire responses for objective 5 ... 249 Table 9-23 – Questionnaire responses for objective 7 ... 250 Table 9-24 – Questionnaire responses for objective 8 ... 251 Table 9-25 – Questionnaire responses for objectives 10 ... 252 Table 9-26 – Questionnaire responses for objective 6 ... 252 Table 9-27 – Questionnaire responses for objective 11 ... 253 Table B-1 – Categories of capabilities related to the patient (Key:
POC=point-of-care; EPR=electronic patient record; PC=personal computer; LP=landline phone; TV=television) ... 319 Table B-2 – Categories of capabilities related to the caregiver (Key: PC=personal computer) ... 320 Table B-3 – Categories of capabilities related to the health professional (Key: EPR=electronic patient record; PC=personal computer; LP=landline phone; MP=mobile phone) ... 322 Table B-4 – Categories of capabilities related to other system entities (Key: EPR=electronic patient record) ... 324 Table D.3-1– Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 3-1 ... 335 Table D.3-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 3-3 ... 335 Table D.4-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 4-2 ... 337 Table D.4-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 4-3 ... 338 Table D.5-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 5-3 ... 340
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Table D.5-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 5-5 ... 341 Table D.6-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 6-1 ... 343 Table D.6-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 6-2 ... 344 Table D.6-3 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 6-3 ... 345 Table D.6-4 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 6-4 ... 346 Table D.7-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 7-3 ... 348 Table D.7-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 7-4 ... 349 Table D.8-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 8-4 ... 352 Table D.8-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 8-6 ... 353 Table D.10-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 10-2 ... 357 Table D.10-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 10-3 ... 357 Table D.10-3 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 10-4 ... 358 Table D.11-1 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 11-1 ... 362 Table D.11-2 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 11-2 ... 363 Table D.11-3 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 11-3 ... 364 Table D.11-4 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 11-4 ... 365 Table D.11-5 – Methodological steps 5-6; i.e. possible actions and equivalent capabilities for the proposed telehealth system for 11-5 ... 366
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LIST OF ABBREVIATIONS
AST Alternative site testing
CDSS Clinical decision support system CHF Congestive heart failure
COPD Chronic obstructive pulmonary disease DSS Decision support system
ECG Electrocardiogram EPR Electronic patient record
ETL Extraction Transformation Loading FDA Food and Drug Administration GP General practitioner
GPRS General Packet Radio Service HCU Hand-carried Cardiac Ultrasound ICU Intensive care unit
LOC Lab-on-a-chip
MeSH Medical subject headings
MHRA Medicines and Healthcare products Regulatory Agency NHS National health service
PCT Primary Care trust POCT Point-of-care Testing PSS Product-service system TAT Test turnaround Time
TSA Telecare services association UML Unified modeling language VTE Venous thromboembolism WHO World Health Organization
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1 Introduction
1.1 Background
The administration of healthcare has been traditionally based on health professionals playing the most active role. Speedie et al. (2008) emphasised that existing care models should not be replicated by using new technologies but the development of new models is needed.
The global drivers advocating this change in healthcare administration are: the ageing population and a change in demographics since people are living longer in many developed societies (Department of Health, 2008b; World Health Organization, 2004, 2008c; Saranummi et al. 2006; Wakefield, 2003); the upsurge in the use of technology to access information (information is widely available to the general public and the internet has made this easier, with healthcare not being exempted) (Department of Health, 2008b); the advancement of science (recent discoveries have enabled scientists to have a greater understanding of diseases and their treatment) (Department of Health, 2008b); and the rise in certain conditions due to change in lifestyle (obesity related diseases, cancer and other chronic conditions are becoming prevalent) (Department of Health, 2008a, 2008b).
A multi-faceted approach (which considers multiple research techniques) is required in responding to these challenges which may involve the development of new care delivery models, the use of technology and a change in the mindset of individuals about healthcare.
1.2 Motivation
At the beginning of this research, initial investigation showed that informatics on point-of-care devices was limited to basic data generation and processing.
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Decision support for patients rarely occurred at the point of use of the device. Instead data were usually transferred to an external source.
This research sought to understand how information could be generated from point-of-care devices to support patients in making decisions about their health. It also considered the components (actors and devices) involved in the process of patients generating data to receiving information.
The findings from this research will help in planning healthcare systems in the future that will comply with the trend of government requirements to empower patients.
1.3 Overall Context
This thesis covers information systems as an aid to providing decision support to patients with chronic diseases. Although this thesis is not focussed on knowledge management, the author covers an aspect of knowledge in the literature with regards to supporting decision making for patients. The aspect of literature covering knowledge considers how data is translated to information and then knowledge. Data refers to a set of elements (Saint-Onge, 1996). Information is when data has been organised into a structure, thereby providing context for the data (Saint-Onge, 1996). Knowledge shows understanding of the information (Saint-Onge, 1996). There are two aspects of knowledge: (i) explicit (this is formal and systematic; it can be communicated methodically) and (ii) tacit (this may be based on an individual‘s experience and may be difficult to express and formalise) (Nonaka, 1991).
1.4 Link to thesis chapters
This thesis is a compilation of publications written during the course of this research. The thesis considers the state-of-the-art in current models of
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delivering healthcare and proposes methods of how these may be improved to meet the changing demands worldwide to bring about a change in its delivery. One way in which healthcare delivery can be changed is through telehealth and that is one of the main themes within this research. The other themes encompassing this research are: point-of-care devices, long term conditions, medical and health informatics and decision making/decision support. Section 1.4 defines the terminology used in this research, while section 1.6 provides details of each of the chapters of the thesis and how they are linked together.
1.5 Terminology
This section defines the terminology used in this research. They are: point-of-care devices, telehealth and telemedicine, long term conditions, medical and health informatics and decision making/decision support.
1.5.1 Point-of-care devices
Medical devices are used to diagnose, screen, monitor or treat patients. Their primary aim is not ‗pharmaceutical activity‘, but rather a tool to ‗deliver a service‘ (Summerhayes and Sivshankar, 2006). Medical devices range from hearing aids, to artificial implants in the joints, to ECG (electrocardiogram) machines and ICU (intensive care unit) monitors (Summerhayes and Sivshankar, 2006). Biomedical devices have a biological focus and therefore involve laboratory based features, i.e. such devices would be able to carry out similar experiments as in a standard laboratory, for example, identifying biomarkers in a biological sample.
According to the Medical Subject Headings (MeSH) (2011a), point-of-care systems offer ―laboratory and other services to patients at the bedside‖ which may include ―diagnostics and laboratory testing‖. Point-of-care testing (POCT)
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has been defined as ―diagnostic testing at or near the site of patient care‖ (Kost, 2002). POCT has also been defined by Price and Hicks as ―assays of blood and other fluids‖, not carried out in a central laboratory, but rather close to the patient to give results to facilitate a rapid change in patient care (1999). Hicks et al. (2001) added that such tests could also be done by the patients themselves. Therefore it can be inferred from the descriptions that point-of-care devices are a subclass of medical devices used to carry out diagnostic tests. The description implies that the facilities of a conventional laboratory may be brought to patients irrespective of their location. For instance, patients located in a non healthcare setting will be able to benefit from a point-of-care device. There is a margin of error associated with POCT. According to Meier and Jones (2005), sources of error include: ―the operators‘ incompetence, non adherence to test procedures and use of uncontrolled reagents and equipment‖. They added that the following increased the likelihood of errors: ―incoherent regulation, rapid result availability and immediate therapeutic implications‖. A recent example of errors on a point-of-care device was in a news article recalling a point-of-care device for prostate cancer because it gave people an inaccurate measurement (BBC, 2009). POCT errors therefore suggest that they should not be used in isolation but used to give an initial indication to enable the appropriate decision to be made which may include further testing.
1.5.2 Telehealth and telemedicine
Telehealth is defined as ―the use of information, computing and telecommunications technologies to provide‖ health related services when health professionals and patients are separated by a distance (Fitzmaurice, 1998). Koch (2006) added that telehealth has developed from telemedicine but also includes ―health promotion and disease prevention‖.
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Telemedicine is the use of ―advanced telecommunication technologies to exchange health information‖ and to provide services irrespective of location (Reid, 1996; Picot, 1998).
Anecdotal evidence suggests that differences exist between telehealth and telemedicine: Global Media (2011) suggested that telehealth includes both clinical and/or non-clinical services whereas telemedicine refers to clinical services only; the Telecare Services Association (TSA) suggested that telehealth refers to remote patient monitoring of an individual‘s condition at home, while telemedicine relates to health professionals consulting at a distance (TSA, 2011).
In literature, the terms have been used interchangeably and therefore both have been considered in this research.
A recent government report on healthcare showed that in order for the NHS (National Health Service) to be sustainable in the future, its focus must change to improving people‘s health rather than treatment alone (Department of Health, 2008b). Although the concept of telehealth has been available for some time and its benefits known on small scale projects, there is limited peer-reviewed literature supporting its efficacy on a wider scale. During the course of this research, the UK government conducted a large scale project to see the impact of telehealth and telecare1. However the full impact is yet to be published.
1.5.3 Long term conditions
Long term conditions have been defined by the UK Department of Health as conditions which cannot be currently cured but can be managed through ―medication and other therapies‖ (Department of Health, 2008a). It was
1 Telecare is the delivery of ―health and social care services to people in their own home‖
through telecommunications technologies. It is ―characterised by continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living‖ (Brownsell and Bradley, 2003).
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estimated that 15.4 million people in England have a long term condition (Department of Health, 2008a). Examples of such conditions include: hypertension, asthma, diabetes, coronary heart disease, stroke and transient ischaemic attacks, chronic obstructive pulmonary disease (COPD) etc. The named conditions are the most prevalent in England (Department of Health, 2008a). Figure 1-1 shows five long term conditions linked by arrows. This was achieved by analysing different conditions and how they are currently being managed. The image illustrates that some of the diseases are risk factors for developing other conditions.
Figure 1-1 – Risk factor links between chronic conditions. (1: Nichols and Moler (2010); 2: Adler et al. 2000; 3: Whaley-Connell et al. 2008; 4: Kissela et al. 2005)
1.5.4 Medical and health informatics
Informatics can be defined as a method of processing stand-alone data into information thus allowing it to be interpreted for a specific purpose. It is the application of computational methods to data in order to: classify them; store in a repository by making associations in the data; retrieve the data in an efficient
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manner when needed (efficient, in this context denotes speeding up the rate at which a process occurs to deliver the information needed); and disseminate the data effectively to the resource requiring it (Merriam-Webster, 2011c).
The main emphasis is that tasks that would normally take a significant length of time, using manual methods, are carried out efficiently and speedily, using informatics, thus saving time and allowing more complex sophisticated analysis to be carried out.
Health is the general well-being of the body (Merriam-Webster, 2011a), while medicine is an intervention used to restore, preserve or treat a disease or condition affecting a person‘s health (Merriam-Webster, 2011b). Medical informatics or health informatics is the application of computational methods to aid in maintaining the general well-being of the body. This may be to help in diagnosing conditions and/or proposing the best type of treatment to give to a patient. There are different definitions for medical informatics, however the following provides a good summary: ―the scientific field that deals with biomedical information, data and knowledge - their storage, retrieval and optimal use for problem solving and decision making‖ (Shortcliffe and Blois 2001).
Informatics covers several sub domains (MeSH, 2011b) which are shown in Table 1-1. This research considers medical and health informatics since both terms have been used interchangeably in the past.
28 Sub domain name Description
Dental informatics
―The application of computer and information sciences to improve dental practice, research, education and management‖.
Medical informatics ―The analysis and dissemination of data‖ to different areas of healthcare and medicine.
Nursing informatics Supporting systems within nursing.
Public health informatics
Application of information and computer science and technology to the practice and research of public health i.e. considering populations rather than individuals.
Table 1-1 – Sub domains of informatics (MeSH, 2011b)
1.5.5 Decision making/decision support
Decision making is the combination of cognitive processes that are considered before making a conclusion about the appropriate action to take (Dictionary.com, 2011).
A decision support system (DSS) has been defined as a class of computerised information system that supports business and organisational decision-making activities (Information Builders, 2011). It may be based on a set of algorithms. For instance, one may need to make a choice between several solutions and a DSS may be able to ascertain the optimal solution thus helping the user to make an informed choice. DSSs have benefits associated with them and these include increasing the efficiency of arriving at a solution and improving problem solving.
A clinical DSS (CDSS) uses patient data to generate specific advice (Wyatt and Liu, 2002). Hunt et al. (1998) expand the definition of a CDSS to an automated process for comparing patient-specific ―characteristics‖ against a ―computerised knowledge base‖ where ―recommendations are presented to the provider at the time of clinical decision making‖. This definition implies that CDSS are designed for health professionals as the primary user. Other examples found in literature of DSSs used in healthcare are shown in Table 1-2.
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More literature is available for health professionals (rather than for patients) as the primary users of decision support systems. However, this research focuses more on empowering the patient in becoming the primary decision maker in managing their long term condition. This is not to say that health professionals will be excluded from the decision making process but rather providing a supporting role to patients so that they have a better understanding of their condition.
Use of DSS Primary user of DSS Reference
Observing patient blood glucose levels. Health professional Ford, 2007 Gait2 analysis in rehabilitative
medicine. Health professional Wu et al. 2007
Supporting trainee nurses in clinical
decisions. Health professional
Fortier et al. 2005
Monitoring post triage patients. Health professional Curtis et al. 2008
Supporting informed decision making for the type of prenatal3 test for foetal abnormalities.
Patient Nagle et al.
2006
Table 1-2 – Examples of DSSs used in healthcare
1.6 Research goals
1.6.1 Research contextThis research is set within the context of a crossover project in Cranfield University between Product-Service Systems (PSSs) and Micro Manufacturing. The aim of the crossover project is to ―develop methodologies to facilitate the design of PSSs in which a complex micro-integrated device forms the physical core of the system‖.
2 Gait: a person‘s manner of walking (Oxford Dictionary, 2011a).
3
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A PSS is an ―integrated product and service offering that delivers value in use‖ (Baines et al. 2007). Micro Manufacturing produces devices at the micro scale level. An example is a blood separating device which could be applicable in developing a future point-of-care device that could be used to analyse a pregnant woman‘s blood for conditions that may affect the unborn baby.
This research considers informatics as an aid to service delivery for point-of-care devices.
1.6.2 Research aim
To model and analyse information generation and exchange in telehealth systems and to identify and analyse the capabilities of these systems in managing chronic diseases which utilise point-of-care devices.
1.6.3 Research objectives
Six objectives have been defined to help meet the research aim and they are as follows:
1. To review the state-of-the-art in informatics and decision support on point-of-care devices.
2. To assess the current level of servitization of point-of-care devices used within the home environment.
3. To identify current models of information generation and exchange for point-of-care devices using a telehealth perspective.
4. To identify the capabilities of telehealth systems. 5. To evaluate key components of telehealth systems.
a. Point-of-care devices. b. Intermediate devices.
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6. To analyse the capabilities of telehealth systems as enablers to a healthcare policy.
1.6.4 Research approach
A multidimensional approach was used to tackle the objectives. This was necessary to enable the models of information generation and exchange within telehealth systems to be captured and to identify the capabilities of such systems. It is illustrated in Figure 1-2.
The thesis begins with a literature review to understand the state-of-the-art in informatics pertaining to point-of-care devices.
Review of literature
A critical literature review was carried out to identify how information was obtained and presented to users of point-of-care devices in order for them to make informed decisions about their health.
The process involved a systematic searching of electronic databases (Scopus, ISI Web of Knowledge) using a few keywords initially: informatics and point-of-care devices. The titles and abstracts of the literature retrieved in the search were scanned to identify relevant ones. The search was refined to include a combination of the following keywords: state-of-the-art, bioinformatics, biomedical devices, decision support, decision making, health informatics, informatics, medical devices, point-of-care devices and point-of-care.
The major themes emerging from the literature were decided based on the nature of the topics covered in the literature. These themes were point-of-care devices, data processing and communication, decision support systems and human issues. A simple hierarchical health informatics model (Desrosieres, 1998) (which comprises
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three parts: data, information and knowledge) was found and literature was presented under these three parts.
A separate literature review was carried out to outline the current level of servitization for POCT devices using glucometers as a focus. The literature used in this sector were similar to those of the first literature review, however they were viewed from the perspective of point-of-care devices providing services to users. Questions on factors influencing the choice of users and additional features they would like to see in future glucometers were added to three online forums to receive feedback from users of glucometers.
It was ascertained that glucometers were supplied as products with additional functionalities. It was proposed that in future, they could be supplied within a result-oriented PSS, whereby more services could be provided through them.
A review for telehealth was incorporated in the background of the studies carried out.
Studies
Five major studies were undertaken in this research.
Study 1. A survey of 11 UK based telehealth organisations was completed. An online search was carried out using the following keywords: point-of-care devices, telehealth, telemedicine, eHealth, home telehealth solutions UK, telemedicine services and telehealth companies. This helped to identify UK organisations offering telehealth services. Symbols were invented to represent telehealth offerings diagrammatically since there were no formal tools with flexibility to represent entities and information exchange routes. Content analysis was carried out on the organisations‘ documentation to ascertain the entities involved in exchanging data and information. Once the diagrammatic representation of the telehealth offering was drawn, it was sent to each organisation in the form of a questionnaire to ascertain whether the details in the diagrams were accurate. The questionnaires were sent by email
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to appropriate contacts in the organisation. Each organisation was asked to make modifications if the diagrams were incorrect.
On return of the questionnaire, by 6 of 11 organisations, the diagrams were modified.
Study 2. Capabilities of existing telehealth offerings (study 1) were derived by analysing their characteristics.
The list of capabilities was complied by content analysis of each telehealth offering diagram and recording the flow of data and information through the system. Once the list of capabilities were compiled, similar ones were grouped together based on a hierarchical methodology. This method ranked actors (human entities) higher than other entities of the system. Entities initiating actions were considered above entities affected by outcomes. The categories of capabilities were then represented in diagrams for easier viewing.
A subset of key components identified in the baseline model4 of telehealth offerings was evaluated. This subset was based on the types of devices used within the offerings since the research had a foundation which considered devices. The purpose of these studies was to understand the role of the devices in generating information.
Study 3. The glucometer was chosen as a case-study for evaluating point-of-care devices because it was ubiquitous and represented the state-of-the-art of point-of-care devices used within the home environment. 100 glucometers were evaluated through examination of their manuals and manufacturer documentation. A set of informatics criteria to ascertain the quantity, types of information and advice provided to the patient was noted in a table before being analysed.
Study 4. Intermediate devices are identified in this research as one of the key components of telehealth systems. They are defined in this research as
4
Baseline model: Model representing the entities that were common to all telehealth offerings (Adeogun et al. 2011a).
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connectors between point-of-care devices, patients and health professionals. These were investigated using two approaches. The first, considered the different types available, where they could be used and who used them in telehealth systems. This involved scanning the telehealth offerings (study 1) and constructing a diagram showing each intermediate device located in between two other entities. These diagrams were analysed and the data from this were summarised in tables.
The second considered capabilities of a specific type of intermediate device – proprietary5 devices. In this, all the proprietary devices used in evaluated telehealth offerings were considered. Three more intermediate devices were added to the evaluation following an internet search. Questions were composed to ascertain the following about the devices: setup/configuration, available features, inputs and outputs. The results were analysed.
Study 5. Telehealth is considered in this research as one solution in changing the current delivery of healthcare, therefore, the capabilities of telehealth systems (study 2) were applied to a UK government health report. The UK was chosen since this research is based here.
A six-step methodology emerged from identifying objectives in the report to applying capabilities of telehealth systems to them. The six steps are as follows: (i) identifying the government objective; (ii) summarising what the government objective entails; (iii) extrapolating the actions proposed by the government to meet the objective; (iv) assessing whether a telehealth system is feasible for the objective; (v) proposing actions to meet the government objectives; and (vi) matching equivalent capabilities of telehealth systems to the proposed actions.
A questionnaire was constructed showing the first three steps applied to all objectives. The questionnaire then asked potential respondents whether a telehealth system was a feasible solution for the objective and what would be expected capabilities. A short presentation was recorded (using Windows
5
Proprietary device: a device designed to fulfil a specific role of exchanging data/information between entities of telehealth systems (Adeogun et al. 2011a).
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Movie Maker) to accompany the questionnaire. The questionnaire and the recording were added to a website and the link was disseminated to potential respondents via email. The questionnaire was sent to a total of 14 people who were health professionals, telehealth service providers and telehealth researchers. Six of them replied.
Validation
Validation was performed for individual studies where appropriate.
For study 1, the diagrammatic representations of the telehealth offerings were evaluated by sending questionnaires to all organisations concerned. As a result of the feedback, the diagrams were refined.
For studies 3 and 4, organisations were contacted and data gathered about the devices were refined.
For study 5, experts within the telehealth industry and health professionals validated the results through a questionnaire. The questionnaire showed steps 1-3 of each government objective and then asked respondents to decide whether a telehealth system is possible in step 4. The respondents were also asked to provide reasons for their answers.
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Figure 1-2 – Approach followed in this research (the details of methods used are shown in grey)
1.7 Thesis Structure
This section provides details of each of the chapters of the thesis and how they are linked together. This thesis is a compilation of publications written during the course of this research. It comprises 12 chapters.
1.7.1 Introductory chapters
Chapter 1 is the introduction and sets the scene for the thesis. It provides the background to the research, the research goals and the approaches used in the
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research. It also shows the overall storyline of how the chapters are related and fit into the research.
Chapter 2 is the literature review (part 1) which details an in-depth and critical analysis of literature. It outlines the current state-of-the-art of informatics on several point-of-care devices suitable for managing chronic conditions.
The outcomes of the literature review revealed that information synthesis on point-of-care devices was limited and data were usually transmitted to an external location in order for information to be provided to users.
Chapter 3 is the second literature review which considers point-of-care devices as a means of providing a service (in the form of information) to users. In this chapter, it was ascertained that point-of-care devices are supplied as products with additional functionalities. The level of servitization of point-of-care devices can be increased through a result-oriented PSS.
1.7.2 Studies
Chapter 4 sought to investigate where information was generated, following the discovery that data from point-of-care devices were transferred to an external location (chapter 2). This led to an identification of the arrangement of entities forming telehealth systems. Although telehealth systems are used in many parts of the world including both developed and developing countries, a decision was made to focus on systems within the UK only, due to time constraints. 12 telehealth systems were evaluated. The outcomes of the chapter include the discovery of models of information exchange within these systems: the baseline, dominant and fully-featured models. The baseline model showed entities common to all 12 telehealth systems. The dominant model showed entities present in more than 6 of the telehealth systems. The fully-featured model is a hypothetical model comprising all the entities and their functionalities.